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病历摘要男,4月。因发热9天,咳嗽、腹泻4天于1992年3月入院。系第一胎足月剖宫产。热呈持续型,在38.2～39℃间。单声咳嗽伴粘液痰,无气急、青紫;大便每日4～5次,无粘液脓血。食欲正常,无少尿。体检:T38.4℃,P112次/分,R32次/分,一般情况可,生长发育良好。前囟1.5×1.5cm,平,口唇干裂,皮肤弹性差。面部、腰背部及两下肢可见散在丘疹。颈软,咽红,淋巴结未及。胸廓无畸形,两肺闻及粗罗音。腹平,肝肋下3cm,质尚软,脾肋下
Medical summary Male, April. 9 days due to fever, cough, diarrhea 4 days in March 1992 admitted. Department of full-term cesarean section. The heat was sustained, at 38.2 ~ 39 ℃. Single cough with mucus sputum, no urgency, bruising; stool 4 to 5 times a day, no mucus pus and blood. Normal appetite, no oliguria. Physical examination: T38.4 ℃, P112 times / min, R32 times / min, the general situation can be, good growth and development. Anterior fontanel 1.5 × 1.5cm, flat, dry lips, skin elasticity is poor. Facial, lower back and lower extremity visible scattered pimples. Neck soft, throat, lymph nodes and time. Thorax without deformity, both lungs smell rough rum. Abdomen flat, liver ribs 3cm, the quality is still soft, spleen ribs